— 心理社會完整性 · MEDIUM · MCQ —
一位 45 歲憂鬱症病人表示：「我是一個失敗者，活著沒有意義了。」護理師的首要行動為何？
A 45-year-old client diagnosed with depression states, 'I am a failure and have no reason to live anymore.' What is the nurse's priority action?
- AExplore the reasons for the client's feelings of failure探索客戶失敗感的成因
- BEnsure a safe environment by removing harmful objects透過移除有害物品來確保安全環境
- CEncourage the client to participate in group therapy鼓勵客戶參與團體治療
- DAssess the client's suicide plan and intent✓ 正解評估客戶的自殺計畫與意圖
— Explanation · 中文詳解 —
面對表達自殺念頭的病人，護理臨床實務首重評估自殺風險的具體程度（計劃、工具、可行性）。雖然確保環境安全很重要，但未釐清風險前，護理師需透過直接詢問釐清自殺意圖與危險性，以決定是否需要啟動最高等級的自殺防護計畫（如一對一觀察）。
The priority nursing action is to directly assess the client's suicide plan and intent to determine the level of risk. While ensuring a safe environment is crucial, the nurse must first clarify the immediacy and specificity of the threat through direct questioning to decide on the appropriate safety interventions.
✦ 台美臨床差異
美國法規極度強調 Suicide Assessment Tool 的紀錄；台灣臨床通常直接轉介專科醫師並加強觀察，紀錄較偏向護理紀錄呈現。